02 December 2010

A commenter posted the following question on the last post, about the economics of drug abuse:

Based on your experience as an ER doctor, I was wondering what your thoughts are on the drug use, specifically the drug war. Do you see legalization as an option for some drugs? What do you think of the Portuguese model of decriminalization and treatment?

Will drug users just always be drug users?

Far be it from me to opine on something that's not really my field of expertise. Wait, no, never mind, that's pretty much my stock in trade around here: wildly unsupported opinions about whatever occurs to me at any given moment. So here goes!

First of all, the easy one: Pot. That should be decriminalized. It's not exactly benign, but it's probably less dangerous than alcohol, and it is inarguable that the black market for pot funnels a LOT of money into dangerous drug cartels. More to the point, it's just not the case that marijuana addiction necessarily harms people any more than alcohol, and I think that for consistency if you're gonna prohibit something it should be worse than the things you leave legal. I favor pot because it's largely harmless and my inner libertarian thinks the government shouldn't prohibit an activity absent compelling proof it is in the public interest. Pot fails that standard. Legalizing pot has practical policy benefits that we've all heard hashed to death in the wake of Prop 19, so I won't belabor the point.

But I think that is not what the reader was asking about, and that the real question revolves around the harder drugs: should they be legalized? In this case, my answer is no, I think they should remain illegal. This is a case where my inner libertarian yields to my inner paternalist. The hard stuff: meth, cocaine and heroin are potent. Really potent. These drugs have such a powerful effect on the brain that they drive behaviors that are all but impossible for people to control. Not all, but a predictable and significant number of people. It robs them of their agency, because the desire to obtain more drugs is so overwhelming that addicts cannot control it. They say meth is so great that all it takes is one time to hook someone for life. They're too dangerous, and too unpredictable. Nobody who uses them for the first time can predict in advance whether they will be able to use them responsibly and occasionally (which is possible for some) or whether they will become enslaved to a lifelong addiction. Nobody makes an informed decision to become an addict: they make a mistake and get trapped. And the life-wrecking power of these drugs is so obvious that I don't need to expand on the point, but meth in particular seems to do something to the frontal lobes that fries them; chronic meth users are functionally lobotomized. It's terrible.

So these drugs are so dangerous that I think it is essential that the government continue to make them illegal. But, as I said, the interdiction strategy has completely and utterly failed. I'm not saying that we should give up on stopping the drug traffickers, but that a lot of resources spent on that effort could be redirected elsewhere with a lot of benefit. Economics dictates that where there is sufficient demand, supply will develop to meet it. Ignoring the demand problem while trying to kill the suppliers is like fighting entropy: it's a futile effort.

So how do we stop demand? Sure, sure education in schools and "just say no" and all that is good stuff, but it's clearly ineffective. If we cannot prevent the drugs from getting to market, and we can't, then we also can't stop people from experimenting with them. What we need to do is identify the addicts who can be rehabilitated early and dedicate the resources to getting them off -- and keeping them off.

There's loads of evidence that drug treatment works. Not for everybody and maybe not permanently. No cure is perfect. But it massively mitigates the problem, and the return on the investment in drug treatment is equally massive, from the savings in incarceration costs, to less violent crime, to the economic benefits of returning people to the workforce. So we should be redirecting resources from enforcement/punishment to treatment and rehabilitation. There are all sorts of smart, proven strategies, from drug courts to needle exchanges to brief interventions in the ER. Unfortunately, it turns out that in times of recession, the first thing that gets cut is social services. Take this recession, in our liberal state: We lost our state-funded in-ER chemical dependency counselors, we lost at least three local detox centers, and we lost the state-run secure detox facility. The police budget is sacrosanct: that's "Public Safety" and woe to the politician who cuts it. But drug treatment? Ah, fuck 'em. Addicts don't vote.

Which is maddening because it's dumb. Why would you cut the cheapest and most effective tool in your arsenal?

I am obviously frustrated with the current situation, but I should point out that I think a lot of progress has been made in the drug war since the panicky days of the 1980s. Things like needle exchanges were politically controversial -- even radioactive. Now they're accepted and unremarkable (so long as the money is there). Drug courts have gained widespread acceptance. Cocaine, heroin and meth use are all well off their historical peaks. Prescription drug abuse is on the rise, but otherwise, things are steady-to-improving. It's not all doom and gloom

11 comments:

All of my children were exposed to meth prenatally and after birth and the effects on their brains have been devastating. Our daughter became symptomatic first - at 3 years old, she pulled out all her hair. At 4 years old, she tried to kill herself. (No, meth isn't the entire story but it changed how she responds to stimuli.)

While we were looking for treatment, we came across the world's most idiotic public mental health service - the only mental health service in the county, by the way. We were told that as foster parents we had received better training on how to deal with a child who was coming off an addiction and who was actively self-harming.

In our training, we had been told that 78% of children who age out of the foster care system will end up in jail, addicted to drugs, and have biological children of their own in the system. We left that clinic with very little hope that any of us would survive this.

So, I definitely agree with you. The money needs to be put into medical and mental health treatment centers that work together.

The treatment center our kids are with uses as many tools as they can - they found that because of the meth addiction in their bio-mom, there were changes in their brains and they found a medication that helped control the impulses and aggression. They have weekly talk and play therapy and they also have mentors with psychiatry degrees who hang out at school a couple days a week to help take care of problems before it becomes a Big Issue.

The kids can learn to "just say no" every day but unless we make an impact on their daily life, I doubt we'll see a decrease in users.

I have to admit that I sort of hate it when people say that drugs rob people of their agency. Drug addicts are just as responsible as anyone else for their behaviors and actions though both they and their enablers hate to hear that.I have a new policy in my ER, when drug addicts assault me or a nurse (this is a common theme in my city when they are denied narcotics) the next step in their medical treatment is that I ask the police to charge them. Maybe they really are not in control of their actions, but if that's the case a judge can decide...

While I agree with your general sentiment, I would like to point out that your view of the overall risk of hard drug abuse is a bit overblown. This is an understandable opinion from your position, that of a person who only sees the worst effects of drug use.

However, as someone with a long history of use and abuse of all of the hard drugs (meth, cocaine, and heroin specifically) I can tell you that the vast majority of the users of these drugs never make it to the ER because they manage their habits well. I know this because I've never been to the ER for my drug use, and of the people I've known to use the hard drugs (which is quite a few), none of them have been to the ER either. Note that this is excluding alcohol. I've known more than one person that abused alcohol to need medical assistance as a result of it's abuse.

I also take issue with the statement that no drug addict makes an informed decision about their drug use. This has not been my experience. Drug users are a lot more informed than you give them credit for.

Our local Coroner has a solution to the drug problem - every OD death is ruled a suicide. There's more money available for suicide prevention than drug treatment. Our county now has the highest suicide rate in the world - worse than Belarus or Korea.

[the following comment is related to only four words of the post.]I'm trying to decide just how small SF's inner libertarian is. Does his inner paternalist just kick sand in his inner libertarian's face and take his lunch money, or can his inner paternalist pick up his inner libertain and put him in his pocket?

To anonymous, who said he knows many people in control of their drug use: the post clearly made a distinction between addicts and non-addicts. Alcohol has the exact same characteristics, some can use it responsibly and some can not.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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